Decreasing NICU admissions of asymptomatic infants of women with pregestational diabetes mellitus improves breastfeeding initiation rates

Primiparity, class 3 obesity, intention to breastfeed and breastfeeding initiation

BACKGROUND

During the 2013-21 period, 674 primiparous women with Class 3 obesity delivered in our institution. Their antenatal infant feeding preference on admission was: 518 (77%) intended to breastfeed (BF) only, 101 (15%) intended to feed formula only and 55 (8%) intended to BF and formula feed combined. Intention to BF only is a predictor of BF initiation, however, data concerning this relationship is limited.

OBJECTIVE

To determine the perinatal variables that influence success or failure of BF among primiparous women with Class 3 obesity who antenatally declared their intention to only BF.

METHODS

Retrospective cohort study of women who delivered live singletons without major malformations at ≥ 34 weeks gestation.

RESULTS

The 518 women who prenatally intended to BF only, were categorized at discharge as exclusive BF (EBF) 197 (38%), any BF (ABF) 212 (41%) and formula feeding (FF) 109 (21%). A lower prevalence of gestational diabetes (10,17 vs 17%), chronic hypertension (16,31 vs 18%), severe preeclampsia (12,22 vs 30%), cesarean delivery (37,55 vs 55%), late preterm (6,17 vs 14%), neonatal hypoglycemia (8,26 vs 22%) and NICU admission (11,25 vs 20%) was present in the EBF group as compared to ABF and FF. African American women were more likely to only FF. Regression analysis showed that the stronger predictors of failure to initiate BF were public healthcare assistance, African American race, preeclampsia, cesarean delivery, neonatal hypoglycemia, prematurity and NICU admission.

CONCLUSION

Among primiparous women with class 3 obesity who intended to BF only but failed to do so, the increased prevalence and severity of maternal and neonatal morbidities are likely obstacles to BF their first infant.

Gestational weight gain and patterns of breastfeeding among patients with class III obesity

BACKGROUND

Maternal obesity is associated with delayed lactogenesis and shorter duration of breastfeeding compared to patients with a normal BMI.

RESEARCH AIM/QUESTION

We investigated the impact of excessive gestational weight gain, defined as greater than the Institute of Medicine guidelines (>9.1 kg), on the initiation and duration of breastfeeding in patients with class III obesity.

METHODS

Retrospective cohort of patients with body mass index ≥40 in first trimester, delivering a singleton term infant at a tertiary care center between July 2013 and December 2017. Primary outcome was exclusive breastfeeding at discharge and at postpartum visit. Secondary outcomes included any breastfeeding at discharge and postpartum visit, and cessation of breastfeeding by the postpartum visit. Descriptive statistics were used to compare those whose gestational weight gain exceeded (eIOM) versus met (mIOM) Institute of Medicine guidelines. Regression models were performed to adjust for baseline confounding factors.

RESULTS

Of 294 women included, 117(39.8%) were in the eIOM group. These women were more likely to be primigravida, have a higher delivery BMI, greater delivery blood loss, and have a neonate admitted to the intensive care unit. Exclusive breastfeeding at discharge was not different between eIOM and mIOM (66.7% vs 70.9%, p = .44), nor did eIOM impact likelihood of exclusive breastfeeding at postpartum visit (40.1% vs 34.2%, p = .31). When controlling for confounding factors, breastfeeding at discharge (aOR 1.54 95% CI [0.68-3.49]) or postpartum visit (aOR 0.67[0.31-1.47]) did not differ between eIOM compared to mIOM.

CONCLUSIONS

Among women with class III obesity, excessive gestational weight gain did not impact the rate of exclusive breastfeeding at discharge or postpartum visit.

A Scoping Review of Breastfeeding in Women with Chronic Diseases

Background: Approximately 10-20% of mothers have a chronic disease. Studies on breastfeeding in women with chronic disease span multiple disciplines, and these have not been collated to synthesize knowledge and identify gaps. The objective of this review was to summarize published literature on breastfeeding in women with chronic disease. Methods: We conducted a scoping review of original research and systematic reviews identified in Medline, EMBASE, and CINAHL (1990-2019) and by hand searching on women with chronic diseases reporting on at least one breastfeeding-related topic. Conference abstracts, case-studies, and studies on pregnancy-induced conditions or lactation pharmacology were excluded. Content analysis and narrative synthesis were used to analyze findings. Results: We identified 128 articles that were predominantly quantitative (80.5%), conducted in Europe or North America (65.6%), analyzed sample sizes of <200 (57.0%), and published from 2010 onward (68.8%). Diabetes (42.2%), multiple sclerosis (MS; 19.5%), and epilepsy (13.3%) were the most common diseases studied. Breastfeeding was a primary focus in approximately half (53.1%) of the articles, though definitions were infrequently reported (32.8%). The most-studied topics were breastfeeding duration/exclusivity (55.7%), reasons for feeding behavior (19.1%), and knowledge and attitudes about breastfeeding (18.3%). Less studied topics (<10% of articles each) included milk expression behaviors, breastfeeding difficulties, and feeding supports. Conclusions: Existing literature focuses primarily on diabetes or MS, and breastfeeding behaviors and outcomes. Further research examining a broader range of chronic diseases, with large sample sizes, and sufficient breastfeeding measurement detail can improve our understanding of breastfeeding disparities in this population.

Breastfeeding initiation among women with preeclampsia with and without severe features

BACKGROUND

Timely delivery and magnesium sulfate (MgSO4) are mainstay in the treatment of preeclampsia with severe features (PWSF). Premature delivery, severity of illness and mother-infant separation may increase the risk for breastfeeding (BF) initiation failure.

OBJECTIVE

To compare BF initiation among women with late-onset PWSF treated with MgSO4 to women with late-onset preeclampsia without severe features (WOSF) who did not receive MgSO4.

METHODS

Retrospective study of 158 women with PWSF and 104 with WOSF who delivered at ≥34 weeks. Intention to BF, formula feed (FF) or partially BF was declared prenatally. At discharge, exclusive BF included direct BF or direct BF with expressed breast milk (EBM).

RESULTS

PWSF and WOSF groups were similar in age, race, and obstetric history. PWSF and WSOF differed in primiparity (65 & 51%), late preterm births (73 vs 15%), admission to NICU (44 &17%) and mother (5 & 4d) and infant (6 & 3d) hospital stay. Both groups were similar in intention to BF (80 & 84%), to FF (16 & 13%) and to partially BF (5 & 5%). At discharge, exclusive BF (37 & 39%), partial BF (33 & 31%) and FF (30 & 30%) were similar. Exclusive BF in the PWSF group was 43% direct BF, 28% direct BF and EBM and 29% EBM alone whereas in the WOSF group exclusive BF was 93% direct BF and 7% direct BF and EBM.

CONCLUSION

BF initiation rates for women with PWSF and WOSF were similar. EBM alone or with direct BF enabled infants in the PWSF group to exclusively BF at discharge.

A Florida public health-based endocrine clinic for low-income pregnant women with diabetes

OBJECTIVES

To evaluate pregnancy outcomes of low-income women with diabetes-complicated pregnancies who received care from an embedded, public health-based endocrine specialty clinic (ESC) in Florida.

DESIGN

This program evaluation used retrospective chart data to analyze client characteristics, pre-program and during-program glycemic control, and pregnancy outcomes of women enrolled in a prenatal ESC.

SAMPLE

Ninety-two low-income, pregnant women with type 1/type 2 diabetes or gestational diabetes (GDM) comprised this racially/ethnically diverse sample.

VARIABLES/ANALYSIS

Neonatal outcomes included frequencies of prematurity, hypoglycemia, hyperbilirubinemia, and birth weight-for-gestational-age categories. Differences in maternal HbA1C at program entry and mean HbA1C during ESC care were determined by a Wilcoxon and paired sample t test.

RESULTS

HbA1C levels during ESC care (6.9 ± 1.4) were less than program entry HbA1C levels (7.9 ± 1.8) for women with pregestational diabetes (Z = -3.364, p = .001). Among women with GDM, mean HbA1C values during ESC care (5.5 ± 0.4) did not significantly differ (t(51) = -0.532, p > .05) from program entry HbA1C levels (5.5 ± 0.5), suggestive of glycemic goal achievement. No neonatal hypoglycemia or hyperbilirubinemia cases were observed in both groups. Approximately 11% of births were preterm, and 16% of neonates were large-for-gestational-age.

CONCLUSIONS

A public health-based ESC for low-income pregnant women with diabetes may positively affect pregnancy outcomes.

Prior breastfeeding experience and infant feeding at discharge among women with pregestational diabetes mellitus

OBJECTIVE

To compare multiparous women with pregestational diabetes mellitus (PGDM) with and without prior breastfeeding (BF) experience and to ascertain their infants' feeding type during hospitalization and at discharge.

METHODS

A retrospective cohort study of 304 women with PGDM who delivered at ≥34 weeks gestational age (GA). Prior BF experience and infant feeding preference was declared prenatally. At discharge, BF was defined as exclusive or partial.

RESULTS

BF experience and no experience groups were similar in diabetes type 1 and 2, race and number of pregnancies. Women with no experience had more spontaneous abortions (35 vs 27%), fewer term deliveries (51 vs 61%) and living children (median 1 vs 2). In the current pregnancy, mode of delivery: vaginal (36 & 37%), cesarean (64 & 63%), birthweight (3592 & 3515 g), GA (38 & 37 w), NICU admission (14 & 11%) and hypoglycemia (44 & 43%) were similar. Women with experience intended to BF (79 vs 46%), their infants' first feeding was BF (64 vs 36%) and had lactation consults (96 vs 63%) more often than those without experience. At discharge, women with BF experience were different in rate of exclusive BF (33 vs 11%), partial BF (48 vs 25%) and formula feeding (19 vs 64%).

CONCLUSION

Prior BF experience leads to better BF initiation rates while the absence of BF experience adds a risk for BF initiation failure. A detailed BF history could provide insight into obstacles that lead to unsuccessful BF experiences and may help define appropriate preventive or corrective strategies.

In-hospital formula supplementation and breastfeeding initiation in infants born to women with pregestational diabetes mellitus

OBJECTIVE

To ascertain the rate of in-hospital supplementation as it relates to early breastfeeding (BF) and early formula feeding (FF) and its effects on BF (exclusive and partial) at the time of discharge for infants born to women with pregestational diabetes mellitus (PGDM).

METHODS

Retrospective cohort investigation of 282 women with PGDM who intended to BF and their asymptomatic infants admitted to the newborn nursery for blood glucose monitoring and routine care. Early feeding was defined by the initial feeding if given within four hours of birth.

RESULTS

Of the 282 mother-infant dyads, for 134 (48%) early feeding was BF and for 148 (52%) early feeding was FF. Times from birth to BF and FF (median 1 hr, 0.3-6) were similar, while the time to first BF for those who FF and supplemented was longer (median 6 hr., 1-24). Ninety-seven infants (72%) who first BF also supplemented. Of these, 22 (23%) BF exclusively, 67 (69%) BF partially and 8 (8%) FF at discharge. One hundred seventeen (79%) who first FF also supplemented. Of these, 21 (18%) BF exclusively, 76 (65%) BF partially and 20 (17%) FF at discharge.

CONCLUSION

Regardless of the type of first feeding, the majority of infants born to women with PGDM require supplementation. Even when medically indicated, in-hospital supplementation is an obstacle, albeit not absolute, to exclusive BF at discharge. Parents should be reminded that occasional supplementation should not deter resumption and continuation of BF.